Suzanne Jacob Serruya

O Programa de Humanização no Pré-natal e Nascimento do Ministério da Saúde no Brasil: resultados iniciais

This article evaluates the implementation of the Brazilian Ministry of Healths Program for Humanization of Prenatal and Childbirth Care using data generated by the SISPRENATAL/DATASUS database from the Unified National Health System. From its beginning in June 2000 until December 2002, 3,983 municipalities joined the Program, and 71% of participating municipalities (3,183) reported their health care activities, constituting a database with 720,871 women. Nearly 20% of the women had six or more prenatal visits, and approximately half of them had the postpartum follow-up visit and required lab tests performed in 2002. In addition, 41% of the women had been vaccinated against tetanus. The number of HIV antibody tests was twice that of syphilis during the two-year period. Only a small percentage of women (2% in 2001 and 5% in 2002) received the entire set of prenatal and childbirth care services. The low percentages attest to the need for permanent evaluation aimed at improving quality of care and guaranteeing both high-quality maternal and perinatal results and the inalienable right of women to safe care and well-being during pregnancy and delivery.

Appropriate criteria for identification of near-miss maternal morbidity in tertiary care facilities: A cross sectional study

BackgroundThe study of severe maternal morbidity survivors (near miss) may be an alternative or a complement to the study of maternal death events as a health care indicator. However, there is still controversy regarding the criteria for identification of near-miss maternal morbidity. This study aimed to characterize the near miss maternal morbidity according to different sets of criteria.MethodsA descriptive study in a tertiary center including 2,929 women who delivered there between July 2003 and June 2004. Possible cases of near miss were daily screened by checking different sets of criteria proposed elsewhere. The main outcome measures were: rate of near miss and its primary determinant factors, criteria for its identification, total hospital stay, ICU stay, and number and kind of special procedures performed.ResultsThere were two maternal deaths and 124 cases of near miss were identified, with 102 of them admitted to the ICU (80.9%). Among the 126 special procedures performed, the most frequent were central venous access, echocardiography and invasive mechanical ventilation. The mean hospital stay was 10.3 (± 13.24) days. Hospital stay and the number of special procedures performed were significantly higher when the organ dysfunction based criteria were applied.ConclusionThe adoption of a two level screening strategy may lead to the development of a consistent severe maternal morbidity surveillance system but further research is needed before worldwide near miss criteria can be assumed.

Revisão sistemática sobre morbidade materna near miss

This systematic literature review on maternal near miss aims to evaluate data on the incidence and different operational definitions of near miss. An electronic search was performed in databases of scientific journals and also in the references of the identified studies. Initially, 1,247 studies were identified, 35 of which were comprehensively assessed, with 17 excluded and 18 included. Review of reference lists from these articles identified an additional 20 articles, thus completing 38 studies included: 20 adopting definitions of near miss related to management complexity, 6 to organ dysfunction, 2 with a mixed definition, and 10 according to symptoms, signs, or specific clinical entities. The mean near miss ratio was 8.2/1,000 live births, the maternal mortality index was 6.3%, and the case/fatality ratio was 16:1. The study concluded that there was a trend towards higher incidence of near miss in developing countries and when using near miss definitions by organ dysfunction. The study of near miss maternal morbidity can help improve obstetric care and support the struggle against maternal mortality.

O panorama da atenção pré-natal no Brasil e o Programa de Humanização do Pré-natal e Nascimento

The purpose of this article was to contextualize historically the advent of the Brazilian Ministry of Healths Prenatal and Birth Humanization Program. Its conceptual, philosophical and operational aspects were pointed out through situation and documental analysis. The Program, launched in June 2000, has as its main strategy to guarantee better access, coverage and quality in prenatal care, birth and puerperal care to pregnant women and newborns from a citizens rights perspective. The Program is based on the right to humanization of obstetric and neonatal care as the first prerequisite for adequate follow-up, besides establishing criteria for classification of care and promotion of a bond between outpatient care and the moment of delivery, integrated and with interventions that had strong evidence of being effective. The article presents the Brazilian scenario of prenatal care at the end of nineties, discuss the principles of humanization as requirement for the quality of care, reconstitutes the design and launch of the Program, besides commenting practical aspects of its initial evaluation and challenges for the future.Abstract The purpose of this article was to contex-tualize historically the advent of the Brazilian Ministryof Healths Prenatal and Birth Humanization Pro-gram. Its conceptual, philosophical and operationalaspects were pointed out through situation and docu-mental analysis. The Program, launched in June 2000,has as its main strategy to guarantee better access,coverage and quality in prenatal care, birth and puer-peral care to pregnant women and newborns from acitizens rights perspective. The Program is based onthe right to humanization of obstetric and neonatalcare as the first prerequisite for adequate follow-up,besides establishing criteria for classification of careand promotion of a bond between outpatient care andthe moment of delivery, integrated and with interven-tions that had strong evidence of being effective. Thearticle presents the Brazilian scenario of prenatalcare at the end of nineties, discuss the principles ofhumanization as requirement for the quality of care,reconstitutes the design and launch of the Program,besides commenting practical aspects of its initialevaluation and challenges for the future.

Avaliação preliminar do programa de humanização no pré-natal e nascimento no Brasil

PURPOSE: to evaluate the experience of implementation of the Brazilian Prenatal and Birth Humanization Program (PHPN) in 2001 and 2002, through a population descriptive study. METHODS: the study was performed through documental analysis and using data generated by SISPRENATAL, comparatively evaluating the indicators concerning criteria for prenatal follow-up in different states, regions and period. RESULTS: until the end of 2002, 3983 municipalities joined the Program (72% adhesion) and, among them, 71% reported results, constituting a data base of 720,871 women. In 2002 only 28% of the pregnant women were already registered, 25% before 120 days of pregnancy. Nearly 22% of the women had six prenatal visits, 6% had the post-partum visit and the compulsory tests performed, only 4% had also the HIV test and were vaccinated against tetanus, and 12% had two examinations performed for syphilis. There were important regional variations, generally showing better indicators for the Southeast and South regions. CONCLUSIONS: although the indicators of quality of care showed an improvement from 2001 to 2002, the recorded low percentages attest the need for permanent evaluations and new interventions with the aim of improving the quality of this care, especially in the North and Northeast regions.

Severe maternal morbidity (near miss) as a sentinel event of maternal death. An attempt to use routine data for surveillance

BackgroundTo identify all the records within the Brazilian Hospital Information System (HIS) that contained information suggestive of severe maternal morbidity (near miss); to describe the diagnoses and procedures used; to identify variables associated with maternal death.MethodsA descriptive population study with data from the HIS and Mortality Information System (MIS) files of records of women during pregnancy, delivery and in the postpartum period in all the capital cities of the Brazilian states in 2002. Initially, records of women between 10 and 49 years of age were selected; next, those records with at least one criterion suggestive of near miss were selected. For the linkage of HIS with MIS and HIS with itself, a blocking strategy consisting of three independent steps was established. In the data analysis, near miss ratios were calculated with corresponding 95% confidence interval and the diagnoses and procedures were described; a multiple logistic regression model was adjusted. Primary and secondary diagnoses and the requested and performed procedures during hospitalization were the main outcome measures.ResultsThe overall maternal near miss ratio was 44.3/1,000 live births. Among the records indicating near miss, 154 maternal deaths were identified. The criteria of severity most frequently found were infection, preeclampsia and hemorrhage. Logistic regression analysis resulted in 12 variables, including four significant interactions.ConclusionAlthough some limitations, the perspective of routinely using this information system for surveillance of near miss and implementing measures to avoid maternal death is promising.

Defining and implementing a National Policy for Science, Technology, and Innovation in Health: lessons from the Brazilian experience

The need for clearly-defined health research policies and priorities has been emphasized in the international scenario. In Brazil, this process began in 2003, when a group appointed by the National Health Council proposed 20 sub-agendas to account for the various health research specificities. The second step was to identify research priorities for each sub-agenda during national seminars involving 510 researchers and policymakers. The 2nd National Conference on Science, Technology, and Innovation in Health was held in July 2004. During the preparatory phase, 307 cities and 24 States organized local conferences, involving 15,000 participants. Some 360 health sector delegates were appointed during the local conferences, in addition to those from the education and science and technology sectors. During the Conference, the national policy was approved and 3 other sub-agendas were introduced and approved. The national policy and the priority agenda are currently guiding investments by the Ministry of Health for research and development, and to a certain extent those from the Ministry of Science and Technology as well. From 2003 to 2005, 24 calls for proposals were launched; as a result, 3,962 research projects were submitted and 1,300 financed.

A qualidade do pré-natal no Brasil

A maioria dos programas atuais de atencao pre-natal e originada de modelos desenvolvidos em paises ocidentais, nas primeiras decadas do seculo passado.Embora parcela significativa tenha calendario e conteudo similares, diferem quanto ao tipo de profissionais envolvidos, as praticas recomendadas e realizadas, alem de diferentes taxas de adesao de mulheres1,2. Varios autores tem realizado proficuo debate sobre os modelos de pre-natal, discutindo principalmente as bases cientificas sobre as quais se construiram e os resultados sobre a saude materna e perinatal3-5. Com intencao de conduzir essa discussao, estudo sistematico avaliou diferentes modelos e suas repercussoes, analisando um conjunto de variaveis , baseado em intervencoes com evidencias, e que constituam um modelo, que otimize recursos e nao acrescente riscos as gestantes que nao apresentem complicacoes6. No Brasil, a assistencia pre-natal tem apresentado importantes diferenciais em numerosos aspectos, que vao do acesso, ao numero de consultas, passando por seus conteudos, periodicidade e profissionais de saude envolvidos em sua realizacao7. A realidade do panorama obstetrico, confrontada com as taxas altas de morbimortalidade materna e perinatal, induziram o Ministerio da Saude em 20008, a lancar uma estrategia de acao, com o objetivo de definir um modelo nacional que normatizasse as acoes assistenciais relacionadas, conjugando esforcos para melhorar os resultados observados. O programa proposto, denominado Programa de Humanizacao do Pre Natal ( PHPN)8, trouxe em seu bojo a discussao sobre as praticas pre-natais e suas bases conceituais, em consonância com os modelos utilizados em todo o mundo.

Safety of Benzathine Penicillin for Preventing Congenital Syphilis: A Systematic Review

Objective To estimate the risk of serious adverse reactions to benzathine penicillin in pregnant women for preventing congenital syphilis. Methods We searched for clinical trials or cohorts that assessed the incidence of serious adverse reactions to benzathine penicillin in pregnant women and the general population (indirect evidence). MEDLINE, EMBASE, Scopus and other databases were searched up to December 2012. The GRADE approach was used to assess quality of evidence. Absolute risks of each study were calculated along with their 95% confidence intervals (95% CI). We employed the DerSimonian and Laird random effects model in the meta-analyses. Results From 2,765 retrieved studies we included 13, representing 3,466,780 patients. The studies that included pregnant women were conducted to demonstrate the effectiveness of benzathine penicillin: no serious adverse reactions were reported among the 1,244 pregnant women included. In the general population, among 2,028,982 patients treated, 4 died from an adverse reaction. The pooled risk of death was virtually zero. Fifty-four cases of anaphylaxis were reported (pooled absolute risk = 0.002%; 95% CI: 0%–0.003% I2 = 12%). From that estimate, penicillin treatment would be expected to result in an incidence of 0 to 3 cases of anaphylaxis per 100,000 treated. Any adverse reactions were reported in 6,377 patients among 3,465,322 treated with penicillin (pooled absolute risk = 0.169%; 95% CI: 0.073%–0.265% I2 = 97%). The quality of evidence was very low. Conclusion Studies that assessed the risk of serious adverse events due to benzathine penicillin treatment in pregnant women were scarce, but no reports of adverse reactions were found. The incidence of severe adverse outcomes was very low in the general population. The risk of treating pregnant women with benzathine penicillin to prevent congenital syphilis appears very low and does not outweigh its benefits. Further research is needed to improve the quality of evidence.

O Ministério da Saúde e a política de ciência, tecnologia e inovação em saúde

O setor de ciencia, tecnologia e inovacao (C&T&I) no Brasil experimentou nos ultimos anos avancos significativos que emprestam novas perspectivas a comunidade cientifica, retratadas na sua crescente producao intelectual e na sua marcada presenca no cenario internacional. Nao obstante dificuldades e entraves existentes, iniciativas foram tomadas no âmbito do fomento que visaram a superacao (ainda que muito ha por fazer) desses obstaculos e assim favorecer os avancos registrados. Ao lado das estruturas virtuosas de apoio ao desenvolvimento de C&T&I, com mais de cinco decadas de existencia, a proposicao de criacao de Fundos Setoriais representou, entre outros, um importante aporte a este esforco empreendido pela comunidade tecnico-cientifica. No campo da saude, aliado a sua ja tradicional importância que responde por pouco mais de um terco da producao cientifica no Brasil, registram-se igualmente esforcos e iniciativas bem sucedidas, e neste espaco vale destacar aquelas implementadas recentemente no Ministerio da Saude (MS). Ao resgatar o principio de que a “Politica de C&T&I em Saude e um componente da Politica Nacional de Saude”, ao atender a obediencia de elaboracao, implementacao e acompanhamento de “Prioridades de Pesquisa em Saude” e ao cumprir a necessidade de criacao de uma Secretaria de C&T no âmbito do MS, consignas estas estabelecidas na 1 a Conferencia Nacional de C&T em Saude, realizada em 1994, e reiteradas na 2a Conferencia de C&T&I em Saude, realizada em 2004, a criacao de Departamento de Ciencia e Tecnologia do MS (DECIT) e posteriormente, em 2003, da Secretaria de Ciencia, Tecnologia e Insumos Estrategicos representaram solidos passos para restabelecer a antiga e necessaria articulacao entre os setores de C&T e de Saude na conducao dessas politicas. Assim, observa-se nos dias de hoje marcada e respeitada presenca do MS nas instâncias responsaveis pelo desenvolvimento de C&T&I, como sao o Fundo Setorial de Saude, o Fundo Setorial de Biotecnologia, as instâncias de implementacao da Politica Industrial do atual governo, e ditada, especialmente, pela sua parceria com o Ministerio de Ciencia e Tecnologia e suas agencias ‐ CNPq e FINEP ‐ e com as Fundacoes Estaduais de Amparo a Pesquisa. A partir de 2003, o MS implementou suas iniciativas tanto no que se refere ao financiamento quanto a formulacao de politicas. No bienio 2004/2005, aplicou-se cerca de R